Method and system for monitoring prescription drug data and determining claim data accuracy

ABSTRACT

A method and system for scanning claims data, the method comprising receiving, by a computing system, contract details associated with claims, receiving, by the computer system, prescription transactions data associated with the claims, parsing, by the computer system, the transactions data into column values, and executing, by the computer system, analytics on the parsed transactions. The analytics include comparing the parsed transactions against the contract details for accurate pricing, fees, and accepted treatment protocols concerning dose and quantity, comparing the parsed transactions with independent pricing data that is based on third-party pricing data and drug information, identifying material errors in the parsed transactions, determining withholdings from payment of the claims for a portion above a tolerance level based on the identified material errors. The method further comprising presenting, by the computer system, results of the execution of the analytics to a portal.

RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/936,986 filed Mar. 27, 2018, entitled “Method And System ForMonitoring Prescription Drug Data And Determining Claim Data Accuracy”,which is hereby incorporated by reference.

COPYRIGHT NOTICE

A portion of the disclosure of this patent document contains material,which is subject to copyright protection. The copyright owner has noobjection to the facsimile reproduction by anyone of the patent documentor the patent disclosure, as it appears in the Patent and TrademarkOffice patent files or records, but otherwise reserves all copyrightrights whatsoever.

BACKGROUND OF THE INVENTION Field of the Invention

This application generally relates to analyzing prescription data, andin particular, monitoring pharmacy benefit managers' billing trends toidentify areas of cost containment and potential pharmacy trends thatmay need to be addressed.

Description of the Related Art

Pharmacy claims have been billed without review, by the payer orfiduciary of the payer (broker, agent, or principal) prior to paymentsince the inception of pharmacy benefit management (PBM) services. Thevolume of prescription claims, the lack of transparency in pricing,confusing contract terms or definitions and the unfamiliarcategorizations of medication therapy, make analysis of pharmacy claimscomplicated and slow.

Errors were not apparent to plan sponsors due to the volume of claimsneeding analysis and the delay in time for PBMs to perform their ownreconciliation to identify errors in billing. Typically, thereconciliation process is performed months after the close of a contractyear. Errors were usually discovered during annual audits by consultantsor accounting firms. These audits are typically conducted on arepresentative sample of prescription claims, months after the close ofa contract year with the PBM. Plan sponsors pay these auditing firmssignificant fees while waiting months for the completion of the process.The process of receiving, analyzing, seeking PBM clarification andproducing the final audit findings occurs well after payment for theclaims, making recovery of funds for material errors difficult. PBMs maychoose a legal approach to settling audit recovery claims, which canlead to additional costs and time delays. A settlement may besignificantly in favor of the PBM due to the lack of transparency, theaudit process itself, and the resultant audit fatigue which is not theprimary business of the payer.

Previously, pharmacy costs were such a small percentage of overallmedical expenditures that potential errors were ignored. Today however,with pharmacies representing 20-25% of medical costs and growing fasterthan some medical expenses, the potential savings are significant.

SUMMARY OF THE INVENTION

The present invention provides a method and system for scanning claimsdata. According to one embodiment, the method comprises receiving, by acomputing system, contract details and claims, receiving, by thecomputer system, prescription transactions data associated with theclaims, parsing, by the computer system, the transactions data intocolumn values, and executing, by the computer system, analytics on theparsed transactions. Although the invention(s) in the presentapplication are discussed by way of example with respect to pharmacybenefits, it is understood that the methods and systems described hereinare applicable to other benefits, including benefits provided underhealth and/or dental plans. The analytics include comparing the parsedtransactions against the contract details for accurate pricing, fees,and accepted treatment protocols concerning dose and quantity, comparingthe parsed transactions with independent pricing data that is based onthird-party pricing data and drug information, identifying materialerrors in the parsed transactions, determining withholdings from paymentof the claims for a portion above a tolerance level based on theidentified material errors. In at least one embodiment, the computersystem creates tolerance levels based on current market intelligence,historical data inputs, projected outputs, to create an expectedtolerance level. The method further comprising presenting, by thecomputer system, results of the execution of the analytics to a portal.

The method may further comprise receiving the prescription transactionsdata from a pharmacy benefit manager (PBM) or pharmacy computer. Theprescription transactions data may be received through an applicationprogramming interface (API), Web interface, or a Secure File TransferProtocol (SFTP) server interface. The prescription transactions data maybe received in files or data communications through an API or Webinterface. The contract details may include contract pricing terms anddefinitions, benefit design requirements, contracted administrativecharges, and excluded categories of claims. Parsing the transactions mayfurther comprise extracting and organizing data in the transactions datainto data fields.

The material errors may include at least one of: claims pricesignificantly above the contracted aggregate discount guarantee for adrug's class and source, claims with dispense as written codes (DAW)that are not allowed for brand medications (a price of the genericmedication may be calculated and the amount over the plan sponsor'sportion of the generic price may be withheld), claims with dispensingfees significantly above contracted terms, claims with incorrectadministrative and clinical fees, claims with quantities or days' supplyvalues above the benefit design's limitations with no priorauthorization approvals, incorrect billing for company pay and copaymentamounts, non-formulary medications dispensed with no priorauthorizations, miscategorization of medications with resultantincorrect pricing applied, and claims billed incorrectly to the payerwhen a different payer is the primary. The method may further includedetermining the tolerance level based on an analysis of prescriptiondata from a previous year and trending and statistical analysis ofthird-party pricing data and drug information. The portion may be anentire claim cost that is over contract terms calculations andacceptable variances. The tolerance level may be dynamically adjustedbased on PBM performance. In one embodiment, the tolerance level isdynamically adjusted based on criteria selected from the groupconsisting of: retail brand and generic pricing discounts, retailspecialty pricing discount, mail brand and generic pricing discounts,specialty pharmacy pricing discount, dispensing fees for retail, mailand specialty prescriptions, and pricing discounts for brand and genericzero balance due prescriptions. Parsing the transactions data mayfurther comprise parsing the transactions data using a file formatdefinition to map the transactions data into the column values.

The portal may include a claims scan module that causes monitoring ofthe claims according to claim contractual accuracy and a comparison ofthe claims to invoices from a PBM. The claims scan module may also causegenerating of a post invoice/prepayment analysis of the claims toidentify potential issues for correction prior to a payment of theclaims. In another embodiment, the portal includes a claims scan modulethat causes analysis of the claims based on at least one of: pricing,package size errors, days' supply, patient eligibility, formularyadherence, prior authorizations, DEA scheduled medication rules, DAWcodes, drug categorization, plan design rule, administrative fees, anddispensing fees. The claims scan module may cause generating of billingcycle summary, claims scan summary, review overview, detailed claimsreporting and withhold payment overview. Additionally, claim scanreports may be generated including a claim scan overview report, claimscan-withhold payment claims detail: portal view, claim scan-withholdpayment claims detail: excel output, and claim scan billing cyclesummary report. The portal may include an ongoing monitoring module thatcauses generating of dashboards and reports that identify opportunitiesin the claims to save money or improve care. The ongoing monitoringmodule may also cause monitoring of medication utilization and trends,comparing pricing to a bench market price, identifying opportunities fortherapeutic alternatives, dangerous drug combinations, and measuring PBMadherence to contracted pricing terms. The portal may also include acare insight application that causes monitoring of physician visits,hospital admissions, patient diagnosis and treatment history, andprescription compliance and history.

According to one embodiment, the system comprises a processor, and amemory having executable instructions stored thereon that when executedby the processor cause the processor to receive contract detailsassociated with claims, receive prescription transactions dataassociated with the claims, parse the transactions data into columnvalues, execute analytics on the parsed transactions, wherein theanalytics include the processor to compare the parsed transactionsagainst the contract details for accurate pricing, fees, and acceptedtreatment protocols concerning dose and quantity, compare the parsedtransactions with independent pricing data that is based on third-partypricing data and drug information, identify material errors in theparsed transactions, and determine withholdings from payment of theclaims for a portion above a tolerance level based on the identifiedmaterial errors. The system further comprises the processor presentresults of the execution of the analytics to a portal.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention is illustrated in the figures of the accompanying drawingswhich are meant to be exemplary and not limiting, in which likereferences are intended to refer to like or corresponding parts.

FIG. 1 illustrates a computing system according to an embodiment of thepresent invention.

FIG. 2 illustrates a communication flow diagram of the computing systemaccording to an embodiment of the present invention.

FIG. 3 illustrates a data flow diagram of a data analysis systemaccording to an embodiment of the present invention.

FIG. 4 illustrates a flowchart of a method for scanning claims dataaccording to an embodiment of the present invention.

FIG. 5 illustrates an exemplary billing cycle summary interfaceaccording to an embodiment of the present invention.

FIG. 6 illustrates an exemplary claims scan overview PDF reportaccording to an embodiment of the present invention.

FIG. 7 illustrates an exemplary claims scan summary interface accordingto an embodiment of the present invention.

FIGS. 8 through 10 illustrate exemplary summary of charges interfacesaccording to an embodiment of the present invention.

FIGS. 11 and 12 illustrate a withhold/review payment claims reportaccording to an embodiment of the present invention.

FIG. 13 illustrates an exemplary claims detail report according to anembodiment of the present invention.

FIG. 14 illustrates a claims insight detail report according to anembodiment of the present invention.

FIG. 15 illustrates an exemplary summary view of a claims scan overviewreport according to an embodiment of the present invention.

DETAILED DESCRIPTION OF THE INVENTION

Subject matter will now be described more fully hereinafter withreference to the accompanying drawings, which form a part hereof, andwhich show, by way of illustration, exemplary embodiments in which theinvention may be practiced. Subject matter may, however, be embodied ina variety of different forms and, therefore, covered or claimed subjectmatter is intended to be construed as not being limited to any exampleembodiments set forth herein; example embodiments are provided merely tobe illustrative. It is to be understood that other embodiments may beutilized and structural changes may be made without departing from thescope of the present invention. Likewise, a reasonably broad scope forclaimed or covered subject matter is intended. Throughout thespecification and claims, terms may have nuanced meanings suggested orimplied in context beyond an explicitly stated meaning. Likewise, thephrase “in one embodiment” as used herein does not necessarily refer tothe same embodiment and the phrase “in another embodiment” as usedherein does not necessarily refer to a different embodiment. It isintended, for example, that claimed subject matter include combinationsof exemplary embodiments in whole or in part. Among other things, forexample, subject matter may be embodied as methods, devices, components,or systems. Accordingly, embodiments may, for example, take the form ofhardware, software, firmware or any combination thereof (other thansoftware per se). The following detailed description is, therefore, notintended to be taken in a limiting sense.

The present disclosure includes a system with a claim scan feature thatcan review claims data efficiently and allows the pharmacy plan sponsorto review billed claims and associated errors, post adjudication andprepayment. The claim scan feature can eliminate, or significantlyreduce the need for a detailed annual or bi-annual audit, which iscurrently the industry standard. With the claim scan feature, materialerrors can be identified and withheld from the payment cycles throughoutthe year. The system may receive, process and analyze claims and billingdata and apply all the variables, definitions, and myriad of contractterms, plan benefit design and payment terms to enables the claim scanfeature to identify and report material errors in PBM billing prior topayment.

FIG. 1 presents a computing system according to an embodiment of thepresent invention. The system presented in FIG. 1 includes a pharmacybenefit manager (PBM) system 102, plan sponsor system 104, a dataanalysis system 106, a network 108, a computer 110, a laptop 112, and atablet 114. Pharmacy locations may use client computing devices, such ascomputer 110, laptop 112, and tablet 114 to communicate with PBM system102 via network 108. A client computing device may comprise any deviceincluding a central processing unit and memory unit capable ofconnecting to a network. The pharmacy locations may contract with PBMsystem 102 on prices for various drugs. Computer 110, laptop 112, andtablet 114 may be a part of a pharmacy chain that owns or is associatedwith multiple locations. For example, large pharmacy chains like CVS,Walgreens, Rite-Aid, etc., have multiple retail locations. In suchcases, the pharmacy chain contracts with the PBM system 102 for drugprices, and the locations of the pharmacy chain can use the prices underthe contract.

Network 108 may be any suitable type of network allowing transport ofdata communications across thereof. The network 108 may couple devicesso that communications may be exchanged, such as between servers andclient devices or other types of devices, including between wirelessdevices coupled via a wireless network, for example. A network may alsoinclude mass storage, such as network attached storage (NAS), a storagearea network (SAN), cloud computing and storage, or other forms ofcomputer or machine-readable media, for example. In one embodiment, thenetwork may be the Internet, following known Internet protocols for datacommunication, or any other communication network, e.g., any local areanetwork (LAN) or wide area network (WAN) connection, cellular network,wire-line type connections, wireless type connections, or anycombination thereof. Communications and content stored and/ortransmitted to and from client devices may be encrypted using, forexample, the Advanced Encryption Standard (AES) with a 128, 192, or256-bit key size, or any other encryption standard known in the art.

PBM system 102 may administer and/or process claims data related topayment requests for reimbursement of drugs (e.g., prescription drugs)rendered to a patient. The PBM system 102 may negotiate with one or morepharmacies regarding prices for various drugs (e.g., under a contract oragreement with a pharmacy). For example, PBM system 102 and a pharmacycan form an agreement on how much the plan sponsor 104 will compensatethe pharmacy for certain drugs, although the amount charged by the PBMmay be different from the amount paid to the pharmacy. PBM system 102may also administer and process claims data associated with a healthinsurance plan. For example, a PBM system 102 and a pharmacy determinesunder an agreement what the price for a particular drug will be for ahealth plan. The members of the health plan are charged a certain pricefor the drug based on the benefit design of the plan sponsor andadministered by the PBM. The PBM system 102 communicates this plandesign to the pharmacy.

The pharmacy computer 110, laptop 112, or tablet 114 may submit claimsdata to the PBM system 102 which forwards the adjudicated claims to theplan sponsor system 104 for approval and payment. Plan sponsor system104 in hand may forward the claims data to data analysis system 106 forprocessing. Data analysis system 106 may communicate with a plurality ofPBMs, such as PBM system 102, to obtain information relating to pricesof various drugs. Data analysis system 106 can use the information toanalyze transactions in the claims data against contract terms, benefitdesign, pricing accuracy, fees and accepted treatment protocolsconcerning dose and quantity. A hierarchy of rules and algorithms mayalso be used by data analysis system 106 to identify and categorizematerial errors in the transactions. A portion of the claims data withidentified errors may be calculated and flagged to be withheld to thePBM system 102.

FIG. 2 presents a communication flow diagram of the computing systemaccording to an embodiment of the present invention. Pharmacy computer202 may transmit drug prescription claims data to PBM computer 204. PBMcomputer 204 may aggregate the prescription claims data and submit themto sponsor computer 206. The claims data may be received by sponsorcomputer 206 in real-time or batch through either an applicationprogramming interface (API) or files presented to a Secure File TransferProtocol (SFTP) server. The claims data may include entries for apayment request along with drug pricing, drug quantity or supply,patient eligibility, formulary adherence, prior authorizations, DrugEnforcement Agency (DEA) scheduled medication rules, dispense as written(DAW) codes, drug categorization, insurance information, etc.

Data analysis system 208 may be used by sponsor computer 206 to analyzethe information in the claims data against information stored indatabase 210, such as contract terms, benefit design, pricing accuracy,fees and accepted treatment protocols concerning dose and quantity.Database 210 may include prices of various drugs and drug informationthat have been collected from various sources. Analyzing the informationmay include identifying errors and determining pricing irregularities.An error or pricing irregularity may comprise, for example, an entrywith a drug price that is beyond a certain tolerance for a particulardrug, drug brand, or drug category. Entries including errors and pricingirregularities may be withheld from payment. The requested payment maybe corrected by the data analysis system 208 and any withholdings may bereported. Sponsor computer 206 may authorize payment 212 to PBM computer204 based on the corrected payment. PBM computer 204 may subsequentlytransfer a payment 214 to pharmacy computer 204.

FIG. 3 presents a data flow diagram of a data analysis system accordingto an embodiment of the present invention. Claims data may be processedby a data analysis system to identify errors and anomalies in billingand prices submitted by PBMs or pharmacies. Computing devices (e.g., ofthe plan sponsor) may access the data analysis system via communicationlayer 308 using SFTP 302, API 304, or Web services 306. The computingdevices may include desktop computers, terminals, laptops, personaldigital assistants (PDA), cellular phones, smartphones, tabletcomputers, or servers.

A client profile is created or retrieved to be used in analyzing theaccuracy of a given pharmacy's submission of claims data. The clientprofile may include contract elements, such as contract terms and plandesign elements corresponding to the pharmacy and PBM. Such informationcan be used by a process that loads and prepares data for reporting oftransactions. Claims data may be transmitted to the data analysis systemin files of a format specified from the computing device, such ascomma-separated values (CSV) files. The files may be received in atransaction (310). A file format definition may be loaded as anavailable source-file map to parse and format the incoming data. Thefile format definition may include, for example, column position, columnlength, column format, and column name. Claims data in the file can beloaded into the data analysis system and parsed using the columnposition and name in the definition.

The claims data may be processed in a claims data scan (312). The claimsdata scan 312 may run an analytics engine to generate metrics oranalytics based on the claims data and compare the claims data withvarious third-party pricing data and drug information sources madeavailable from data warehouse 314. The claims data and analyticsgenerated from the analytics engine may be stored to the data warehouse314 and made available to portal 316. Portal 316 may provide reportingof claims and analytic results from the analytics engine.

FIG. 4 presents a flowchart of a method for scanning claims dataaccording to an embodiment of the present invention. A computing systemmay analyze claims data received from PBM or pharmacy computers, or anyother data provider or data warehouse, including insurer computers, etc.The computing system may be accessed by the PBM or pharmacy computerthrough an application (e.g., using an API), Web interface, or a SFTPserver interface. Contract details are received by a computing system,step 402. A contract input or selection may be received from the PBM orpharmacy computer to provide contract details for claims data associatedwith a PBM, pharmacy or pharmacy network. The contract details mayinclude contract pricing terms and definitions, benefit designrequirements, contracted administrative charges, and any excludedcategories of claims. The contract details may be applied againsttransaction claims. The contract details can be applied consistentlyacross the transactions of claims pertaining to a given pharmacy toidentify errors or anomalies.

The computing system receives prescription transactions data of a claimfrom the PBM or pharmacy computer, step 404. The prescriptiontransactions data may be transmitted in files or data communicationsthrough API or Web interface. The transactions data are parsed by thecomputing system into individual column values, step 406. Parsing thetransactions data may include extracting and organizing specific data inthe transactions data into data fields or a format suitable forprocessing. A file format definition may also be loaded for mappingtransmitted files into a suitable format for the computing system. Thefile format definition may include column position, column length,column format, and column name. Claims data transmitted in files can beloaded into the data analysis system and parsed using, for example, thecolumn position and column name in the definition.

Analytics are executed on the parsed transactions data, step 408. Theparsed transactions data may be fed into a claims data scan engine. Theclaims data scan engine may analyze and compare the transactions dataagainst the contract details for accurate pricing, fees, and acceptedtreatment protocols concerning dose and quantity. Additionally, theclaims data scan engine may compare the transactions data withindependent pricing data that may be generated or developed based onthird-party pricing data and drug information using, for example,machine-learning and trend analysis.

Executing the analytics may further include applying a hierarchy ofrules and algorithms to the transactions data to identify and categorizematerial errors. The identified errors for specific claims, e.g., duringa specified billing cycle, may cause dollar amounts to be withheld froma payment for an excess portion above a tolerance level. Some potentialerrors that can result in the withholding of dollars from payment of aclaim may include: claims price significantly above the contractedaggregate discount guarantee for a drug's class and source, claims withdispense as written codes (DAW) that are not allowed for brandmedications (a price of the generic medication may be calculated and theamount over the plan sponsor's portion of the generic price may bewithheld), claims with dispensing fees significantly above contractedterms, claims with incorrect administrative and clinical fees, claimswith quantities or days' supply values above the benefit design'slimitations with no prior authorization approvals, incorrect billing forcompany pay and copayment amounts, non-formulary medications dispensedwith no prior authorizations, miscategorization of medications withresultant incorrect pricing applied, and claims billed incorrectly tothe payer when a different payer is the primary.

The claims data scan engine may determine a tolerance level setting foridentifying claims that are significantly outside of contracted pricingterms or plan benefit design, and calculate a value to withhold frompayment of the claim. The rules and algorithms can also be applied tothe transactions data to calculate a portion of the claims to bewithheld. The portion may be of an entire claim cost that is overcontract terms calculations and acceptable variances. Categories offindings that are most valuable and easiest to defend for the plansponsor can also be determined.

Establishing a tolerance level allows for market variability in pricingand other factors for a plurality of different medications. Thetolerance level may be established by one or more algorithms usingfactors based on findings in an initial summary analysis of prescriptiondata from the previous year and taking trending and statistical analysisthird-party pricing data and drug information to create the tolerancelevel. The level of variance from contracted guarantees and terms may beused to set initial factors used in the calculation of tolerance levels.Additionally, the tolerance level may account for and accommodateaggregate discount terms commonly used in PBM contracts for pricingguarantees. The tolerance levels for pricing discounts and dispensingfees may be dynamically adjusted throughout the year based on PBMperformance. Dynamic calculations may be adjusted based on the goal ofhaving a net balance of zero owed from the PBM to the plan at the end ofthe year, when netted against pricing discount guarantees. For example,the following criteria may be dynamically adjusted each quarter: retailbrand and generic pricing tolerance points, retail specialty pricingtolerance point, mail brand and generic pricing tolerance points,specialty pharmacy pricing tolerance points, dispensing fees for retail,mail and specialty prescriptions, and pricing tolerance points for brandand generic zero balance due prescriptions.

Results of the analytics are loaded to a portal, step 410, or delivereddirectly to the client via API, Web service, or secure filetransmission. The parsed transactions data and results of the analyticsfrom the claims data scan engine may be retained in a data warehouse (ordatabase) for retrieval by the portal. The results may be accessedthrough the portal, along with various reports supporting the resultsand suggestions for withholding payment for specific claims. The portalmay provide access to prescription data. Particularly, the portal mayallow a user to monitor post invoice/prepayment financial trends andanalyze their prescription data on an on-going basis. The portal candeliver actionable data that can be viewed at varying levels of detailbased on user-defined security levels. These various levels of detailmay aid in identifying areas of cost containment and potential pharmacytrends that may need to be addressed. Data provided in the portal mayallow a user to pinpoint problems, such as in pricing, drug utilization,provider performance, and pharmacy benefit manager billing.

According to one embodiment, the portal may include applications, suchas claims insight, provider insight, and care insight. A claims insightapplication may include a claims scan module and an ongoing monitoringmodule. The claims scan module may provide monitoring of claimsaccording to claim contractual accuracy and comparing the claims toinvoices from a PBM. According to one embodiment, PBM performance may bemonitored against user-defined key performance measurements in theclaims scan module. The claims scan module may further generate a postinvoice/prepayment analysis of pharmacy claims, so that any potentialissues may be identified for correction prior to payment to the PBM. Theclaims scan module is described in further detail with respect to thedescription of FIGS. 5-16 .

The ongoing monitoring module may generate dashboards and reports thatenable the user to quickly identify opportunities in prescription claimsdata to save money or improve care. The ongoing monitoring module iscapable of monitoring medication utilization and trends, comparingpricing to a bench market price, identifying opportunities fortherapeutic alternatives, dangerous drug combinations, and measuring PBMadherence to contracted pricing terms.

A provider insight application may provide the ability to monitorprovider prescribing patterns and study these patterns at various levelsof detail and categorization. Provider analysis can be done based onpatient groups, geography, practice, practice specialty or individualprescriber.

A care insight application may allow the user to monitor physicianvisits, hospital admissions, patient diagnosis and treatment history,and prescription compliance and history. By using both prescription andmedical data on the same platform, care managers can prioritize theirworkload to care for the patients in a strategic manner. Care insightdata can be viewed from a general population level down to theindividual patient level.

Claims scan module is operable to generate a per billing cycle reportincluding post invoice/prepayment analysis of pharmacy claims. Materialerrors may be identified and addressed prior to payment to the PBM.Claims scan may analyze critical areas including: pricing, package sizeerrors, days' supply, patient eligibility, formulary adherence, priorauthorizations, DEA scheduled medication rules, DAW codes, drugcategorization, plan design rule, administrative fees, and dispensingfees. Errors and alerts displayed within the claims scan module can becustomizable by the user. The user may establish their own set ofcategories, rules, and factors in claims scan rules.

In one embodiment, the claims scan module includes billing cyclesummary, claims scan summary, review overview, detailed claims reportingand withhold payment overview. Additionally, claim scan reports may begenerated including a claim scan overview report, claim scan-withholdpayment claims detail: portal view, claim scan-withhold payment claimsdetail: excel output, and claim scan billing cycle summary report.

FIG. 5 presents an exemplary billing cycle summary interface accordingto an embodiment of the present invention. Billing cycle summaryinterface 500 includes a billing cycle dropdown 502. A PBM's billingcycles may be selected from a list of available ending dates in thebilling cycle dropdown 502. The billing cycle summary interface furtherincludes file receive data 504 and file run date 506. File receive date504 displays the date the data file was received from the PBM. The filerun date 506 displays the date the file was loaded into for analysis.Claims scan overview PDF 508 may be selected to produce a claims scanoverview report in portable document format (PDF).

FIG. 6 presents an exemplary claims scan overview PDF report accordingto an embodiment of the present invention. Claims with errors may begrouped within a withhold payment claims section of the report. Theclaims scan overview report may include a code column that categorizesthe errors by contract terms, drug types and pharmacy source. The claimsscan overview report may provide a categorized summary of the number ofclaims that should be reviewed or withheld from payment, grouped byreason rationale, and a dollar value for those claims with alerts orerrors based on user-defined rules. A reason column may provide a briefexplanation of the errors and a formula that was used to calculate theamount to withhold or review.

FIG. 7 presents an exemplary claims scan summary interface according toan embodiment of the present invention. The claims scan summaryinterface 700 may provide a high-level summary view of claims with linksto additional claims detail. The claims scan summary interface includesa net claims total 702 that shows a total count and amount ofprescription claims for a given time-period. To view more detail, thesummary of charges 704 button may be selected to view the summary ofclaims count and the dollars associated with each drug category andpharmacy type, as illustrated in FIGS. 8-10 . A summary of chargesreport may provide data on prescription claims (FIG. 8 ), credit returnadjustments (FIG. 9 ), and manual/paper claims and sales tax (FIG. 10 ).

Referring back to FIG. 7 , the claims scan summary interface 700includes a withhold payment claims 706 that displays the claim count andamount of prescriptions for which payment should be withheld, based onthe rules set forth by the client in the claims scan rules. A summary ofthe claims, grouped by the withhold reason, can be viewed by clicking onwithhold payment claims 706. Previously withheld amounts for RX creditreturns 708 may display the count and amount of any claims withpreviously withheld amounts that were reversed. These amounts may becredited against a current withhold amount. Recommended Payment Amount710 may display the total recommended payment amount for the claims inthe selected billing cycle. Review claims 712 may display the count andamounts of claims recommended to be reviewed with the PBM, but notwithheld from the payment amount. A summary of the claims, grouped bythe review reason, can be viewed by clicking on review claims 712.

Withhold payment claims 706 or review claims 712, may be selected togenerate a withhold/review payment claims report, as illustrated in FIG.11 . Values in the withhold/review payment claims report 1100 may begrouped by alert category and include information, such as a withholdamount and a claims count. The withhold amount may indicate a totalamount to withhold from payment for the claims in the alert category.The claims count may indicate the total number of claims in the alertcategory. From the withhold/review payment claims report, a user mayview or download additional claim-level detail by clicking on viewclaims detail 1202, as illustrated in FIG. 12 .

FIG. 13 presents an exemplary claims detail report according to anembodiment of the present invention. The claims detail report 1300includes details on the drug including a description for an alert, fees,contracted price, and amount withheld. The metrics reported on theclaims detail report 1300 may include company, copay, dispensing,contracted prices, and withhold amount. Company may indicate the totaldollar amount billed to the company. Copay may indicate the total amountpaid by the patient. Dispensing may indicate the amount paid for thedispensing fee. Contracted prices may indicate the calculated pricesbased on the contractual price between Client and PBM. Withhold amountmay indicate the amount to be withheld from the payment due to theerror/reason for the alert.

To view claim-level detail, a detail report download link may beselected, for example, from within the withhold/review payment claimsdetail report 1100 or the claims detail report 1300 to produce a claimsinsight detail report 1400, illustrated in FIG. 14 . Claims insightdetail report 1400 may provide claim-level detail for claims recommendedfor review prior to making payment. The metrics reported for each claimin claims insight detail report 1400 may be calculated based on:quantity, average wholesale price (AWP) unit price, unit price paidcompany pay, copay, dispensing fee, admin fee, withhold amount, anddescription of criteria. The quantity may refer to the number of unitsin the prescriptions claim. AWP unit price may refer to the averagewholesale price for one unit of the medication. Unit price paid mayrefer to the unit price paid (company pay+copay) to the PBM. Company paymay refer to the total dollar amount paid by the company for the claim.Copay may refer to the total amount paid by the patient in copay.Dispensing fee may refer to the amount paid to the PBM/pharmacy as adispensing fee. Admin fee may refer to the administrative fee paid tothe PBM for the claim. Withhold amount may refer to the amount towithhold from payment for the claim. Description of criteria may referto the contract pricing terms and factors used to determine claims thatsignificantly exceeded the contract guarantees.

FIG. 15 presents an exemplary summary view of a claims scan overviewreport according to an embodiment of the present invention. Claims scanoverview report 1500 may include a summary for claims to be reviewed(review overview 1502) and claims in which payment is recommended to bewithheld (withhold payment overview 1504).

FIGS. 1 through 15 are conceptual illustrations allowing for anexplanation of the present invention. Notably, the figures and examplesabove are not meant to limit the scope of the present invention to asingle embodiment, as other embodiments are possible by way ofinterchange of some or all of the described or illustrated elements.Moreover, where certain elements of the present invention can bepartially or fully implemented using known components, only thoseportions of such known components that are necessary for anunderstanding of the present invention are described, and detaileddescriptions of other portions of such known components are omitted soas not to obscure the invention. In the present specification, anembodiment showing a singular component should not necessarily belimited to other embodiments including a plurality of the samecomponent, and vice-versa, unless explicitly stated otherwise herein.Moreover, applicants do not intend for any term in the specification orclaims to be ascribed an uncommon or special meaning unless explicitlyset forth as such. Further, the present invention encompasses presentand future known equivalents to the known components referred to hereinby way of illustration.

It should be understood that various aspects of the embodiments of thepresent invention could be implemented in hardware, firmware, software,or combinations thereof. In such embodiments, the various componentsand/or steps would be implemented in hardware, firmware, and/or softwareto perform the functions of the present invention. That is, the samepiece of hardware, firmware, or module of software could perform one ormore of the illustrated blocks (e.g., components or steps). In softwareimplementations, computer software (e.g., programs or otherinstructions) and/or data is stored on a machine-readable medium as partof a computer program product, and is loaded into a computer system orother device or machine via a removable storage drive, hard drive, orcommunications interface. Computer programs (also called computercontrol logic or computer-readable program code) are stored in a mainand/or secondary memory, and executed by one or more processors(controllers, or the like) to cause the one or more processors toperform the functions of the invention as described herein. In thisdocument, the terms “machine readable medium,” “computer-readablemedium,” “computer program medium,” and “computer usable medium” areused to generally refer to media such as a random-access memory (RAM); aread only memory (ROM); a removable storage unit (e.g., a magnetic oroptical disc, flash memory device, or the like); a hard disk; or thelike.

The foregoing description of the specific embodiments will so fullyreveal the general nature of the invention that others can, by applyingknowledge within the skill of the relevant art(s) (including thecontents of the documents cited and incorporated by reference herein),readily modify and/or adapt for various applications such specificembodiments, without undue experimentation, without departing from thegeneral concept of the present invention. Such adaptations andmodifications are therefore intended to be within the meaning and rangeof equivalents of the disclosed embodiments, based on the teaching andguidance presented herein. It is to be understood that the phraseologyor terminology herein is for the purpose of description and not oflimitation, such that the terminology or phraseology of the presentspecification is to be interpreted by the skilled artisan in light ofthe teachings and guidance presented herein, in combination with theknowledge of one skilled in the relevant art(s).

What is claimed is:
 1. A method, in a data processing system comprisinga processor and a memory, for scanning claims data, the methodcomprising: receiving, by a computing system, contract detailsassociated with claims; receiving, by the computer system, prescriptiontransactions data associated with the claims; parsing, by the computersystem, the transactions data into column values; executing, by thecomputer system, analytics on the parsed transactions, the analyticsincluding: comparing the parsed transactions against the contractdetails for accurate pricing, fees, and accepted treatment protocolsconcerning dose and quantity; comparing the parsed transactions withindependent pricing data that is based on third-party pricing data anddrug information; identifying material errors in the parsedtransactions; and determining withholdings from payment of the claimsfor a portion above a tolerance level based on the identified materialerrors, and presenting, by the computer system, results of the executionof the analytics to a portal.
 2. The method of claim 1 furthercomprising receiving the prescription transactions data from a pharmacybenefit manager (PBM) or pharmacy computer.
 3. The method of claim 1further comprising receiving the prescription transactions data throughan application programming interface (API), Web interface, or a SecureFile Transfer Protocol (SFTP) server interface.
 4. The method of claim 1further comprising receiving the prescription transactions data in filesor data communications through an API or Web interface.
 5. The method ofclaim 1 wherein the contract details include contract pricing terms anddefinitions, benefit design requirements, contracted administrativecharges, and excluded categories of claims.
 6. The method of claim 1wherein parsing the transactions further comprises extracting andorganizing data in the transactions data into data fields.
 7. The methodof claim 1 wherein the material errors include at least one of: claimsprice significantly above the contracted aggregate discount guaranteefor a drug's class and source, claims with dispense as written codes(DAW) that are not allowed for brand medications (a price of the genericmedication may be calculated and the amount over the plan sponsor'sportion of the generic price may be withheld), claims with dispensingfees significantly above contracted terms, claims with incorrectadministrative and clinical fees, claims with quantities or days' supplyvalues above the benefit design's limitations with no priorauthorization approvals, incorrect billing for company pay and copaymentamounts, non-formulary medications dispensed with no priorauthorizations, miscategorization of medications with resultantincorrect pricing applied, and claims billed incorrectly to the payerwhen a different payer is the primary.
 8. The method of claim 1 furthercomprising determining the tolerance level based on an analysis ofprescription data from a previous year and trending and statisticalanalysis of third-party pricing data and drug information.
 9. The methodof claim 1 wherein the portion is an entire claim cost that is overcontract terms calculations and acceptable variances.
 10. The method ofclaim 1 further comprising dynamically adjusting the tolerance levelbased on PBM performance.
 11. The method of claim 1 further comprisingdynamically adjusting the tolerance level based on criteria selectedfrom the group consisting of: retail brand and generic pricingdiscounts, retail specialty pricing discount, mail brand and genericpricing discounts, specialty pharmacy pricing discount, dispensing feesfor retail, mail and specialty prescriptions, and pricing discounts forbrand and generic zero balance due prescriptions.
 12. The method ofclaim 1 wherein parsing the transactions data further comprises parsingthe transactions data using a file format definition to map thetransactions data into the column values.
 13. The method of claim 1wherein the portal includes a claims scan module that causes monitoringof the claims according to claim contractual accuracy and a comparisonof the claims to invoices from a PBM.
 14. The method of claim 1 whereinthe portal includes a claims scan module that causes generating of apost invoice/prepayment analysis of the claims to identify potentialissues for correction prior to a payment of the claims.
 15. The methodof claim 1 wherein the portal includes a claims scan module that causesanalysis of the claims based on at least one of: pricing, package sizeerrors, days' supply, patient eligibility, formulary adherence, priorauthorizations, DEA scheduled medication rules, DAW codes, drugcategorization, plan design rule, administrative fees, and dispensingfees.
 16. The method of claim 1 wherein the portal includes a claimsscan module that causes generating of billing cycle summary, claims scansummary, review overview, and withhold payment overview.
 17. The methodof claim 1 wherein the portal includes an ongoing monitoring module thatcauses generating of dashboards and reports that identify opportunitiesin the claims to save money or improve care.
 18. The method of claim 17wherein the ongoing monitoring module causes: monitoring of medicationutilization and trends; comparing pricing to a bench market price;identifying opportunities for therapeutic alternatives; dangerous drugcombinations; and measuring PBM adherence to contracted pricing terms.19. The method of claim 1 wherein the portal includes a care insightapplication that causes monitoring of physician visits, hospitaladmissions, patient diagnosis and treatment history, and prescriptioncompliance and history.
 20. A system for scanning claims data, thesystem comprising: a processor; and a memory having executableinstructions stored thereon that when executed by the processor causethe processor to: receive contract details associated with claims;receive prescription transactions data associated with the claims; parsethe transactions data into column values; execute analytics on theparsed transactions, the analytics including the processor: compare theparsed transactions against the contract details for accurate pricing,fees, and accepted treatment protocols concerning dose and quantity;compare the parsed transactions with independent pricing data that isbased on third-party pricing data and drug information; identifymaterial errors in the parsed transactions; and determine withholdingsfrom payment of the claims for a portion above a tolerance level basedon the identified material errors, and present results of the executionof the analytics to a portal.